Scheduling & Case Discussions

1. Contact Information:

First Name: *

Last Name: *

E-mail: *

Phone: *

Address:

City:

State/Providence:

Zip:

Country:

2. Tell us a bit about your case:

Current diagnoses or primary medical concern:*

What are the primary functional goals you are trying to achieve?
For example, resume marathon training, return to college, walk my children to/from school, be able to perform my manual labor job full-time, etc… Functional goals would not be “to feel NORMAL” or “to feel BETTER” as these feelings differ greatly for each person who is suffering from a chronic condition. You could also list some objective ways by which you are measuring the success of the treatments you have already received or are looking to receive.

Have you been recommended surgery by another health care provider?

Yes, and I want to avoid it if possibleNot yet, and I want to avoid the need for one in the future

3. How can we best serve you?

Schedule an appointment at Caring Medical Florida:*

as soon as possiblewithin a couple weekswithin 1-2 monthsI am not looking to schedule an appointment at Caring Medical Florida

Preferred contact method so we can talk with you more about your case:

Please call meI’d prefer email

How were you referred to our office?